aequum White Paper Offers Guidance on No Surprises Act (NSA) for Employer-Sponsored Health Plan Administrators: Risks and Opportunities

aequum LLC announces the publication of its white paper No Surprises Act: What Every Plan Sponsor Needs to Know to serve as a valuable resource for employer-sponsored health plan administrators. It highlights many of the current risks and opportunities that result from the NSA legislation, including a focus on Reference-Based Pricing (RBP) strategies. Free download available here.

Jack Towarnicky, member of aequum, explains, “As of January 1, certain provisions of the No Surprises Act (NSA) took effect to protect health plan participants from balance bills received from out-of-network providers – including services for emergency care and at in-network facilities. It offers benefits professionals guidance regarding the NSA’s provisions and interim final rules – encouraging plan sponsors to respond with an approach that is both strategic and compliance oriented. A dual-approach will minimize compliance challenges, reduce cost of coverage for both the employer and employees, and improve both the perceived and actual value of health coverage.”

Main points of this whitepaper include:

• The Independent Dispute Resolution (IDR) process added by the NSA triggers a new risk for health plans that use RBP with a network of providers or plans that directly contract with providers and facilities.
  
  
  
  
• Providers may challenge RBP determinations even where the NSA doesn’t apply – such as for plans where there is no network of providers, where services are provided in a non-network facility, or by a non-network provider in a non-network facility.
  
  
  
  
• Where the NSA does apply, out-of-network providers who challenge the RBP determinations shift the risk for charges in excess of RBP from the participant to the plan sponsor.

RBP may be subject to the NSA Independent Dispute Resolution process where plans directly contract with facilities and providers. Towarnicky points out that self-funded plans should be aware of this risk, adding, “The most effective way to address this legislation may be to adopt a pure RBP plan which will put the patient in the driver’s seat as a health care consumer.”

“RBP is one of the fastest growing solutions in health benefits cost management,” he continues. “It brings stability to health care prices and point of purchase cost sharing by using Medicare reimbursement rates and other provider cost data to provide an objective cost baseline. This offers disciplined pricing - fair and rational reimbursement for providers.”

About aequum LLC

Founded in 2020, aequum LLC serves third-party administrators, medical cost management companies, stop-loss carriers, employer-sponsored health plans and brokers nationwide to protect plan participants, improve employee satisfaction with their health care plans, and generate plan and participant cost savings. aequum LLC helps patients defend medical balance bills and brings savings to employer-sponsored health plans by providing administrative and other services to its partners. In addition, its sister organization, Koehler Fitzgerald LLC, provides legal advocacy to plan participants. For more information, visit aequumhealth.com.

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